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CONTINUOUS QUALITY
IMPROVEMENT PLAN
FOR
RYAN WHITE TITLE II
HIV/AIDS FUNDS
RECIPIENTS
INSTITUTE FOR INNOVATION IN HEALTH AND HUMANS SERVICES
JAMES MADISON UNIVERSITY
BY
OLAYINKA O. MAJEKODUNMI
BSC HEALTH SCIENCES
JAMES MADISON UNIVERSITY
HARRISONBURG, VA 22807
APRIL 2005
CONTINOUS QUALITY IMPROVEMENT FOR RYAN WHITE
TITLE II FUNDS RECIPIENTS
Chapters
Introduction to Continuous Quality Improvement ………………………………….. 2
Continuous Quality Improvement Plan
Purpose ……………………………………………………………………………………………… 3
Goals and Objectives …………………………………………………………………………… 3
Structure of CQI Plan ………………………………………………………………………….. 4
1. Framework
2. Content
3. Data Collection
4. Assessing and Evaluating
5. CQI Team and Plan
6. Monitoring CQI
7. Communication
Improvement Plan Grid ……………………………………………………………………………. 6
CQI Team Structure ………………………………………………………………………………….. 8
Mission Statement
Purpose
Goals
Team Members
Meeting Schedule
Reporting Structure
CQI Protocol ……………………………………………………………………………………………… 10
Functional Units CQI ………………………………………………………………………………… 11
Administration …………………………………………………………………………………… 11
Primary Medical Care………………………………………………………………………….. 21
Case Management ……………………………………………………………………………... 27
Prevention Case Management …………………………………………………………….. 31
Treatment Adherence ………………………………………………………………………… 36
Substance Abuse ……………………………………………………………………………… 37
Outreach Services/Client Advocacy ……………………………………………………… 40
Nutritional Counseling ……………………………………………………………………….. 42
Psychosocial Support Services ……………………………………………………………. 44
Respite/Home Health Services ……………………………………………………………. 47
Housing ……………………………………………………………………………………………. 50
2
INTRODUCTION TO CONTINOUS QUALITY IMPROVEMENT
Overview of Quality Improvement The Health Resources and Services
Administration (HRSA) have four strategies
HIV/AIDS services organization are dedicated outlined in their program plan. These strategies
and committed to providing quality health and are:
human services to its clients. With a Continuous To eliminate barriers to care
Quality Improvement Plan, the aim is to ensure To eliminate health disparities
a higher standard of care by identifying areas To assure quality of care; and
that need improvement and maintaining To improve public health and health
identified strengths. care systems.
What is Quality Improvement? Ryan White Title II funds recipients are required
to have a quality assurance program in place.
Quality is defined as having a high degree of The following Continuous Quality Improvement
excellence. To achieve this, agencies must plan provides one possible foundation for
develop and implement activities and programs future quality management activities.
that target specific areas that require
improvement. These areas may have previously About this CQI Plan
been identified as deficiencies by the Peer
Review process or may have been identified This plan is based on the Ryan White II Peer
internally. Quality management programs must: Review modules and therefore is broad in its
Assess the extent of the agency’s HIV scope. Agencies may wish to focus on only
services in terms of the Public Health those elements that they have identified as
Service (PHS) guidelines and; requiring immediate improvement and
Develop plans and policies that ensure incrementally working toward addressing
and improve consistency of access to them. While this plan may help pinpoint
quality health care. “trouble spots”, it does not offer all of the
Implementing a quality management program specific action steps (and their commensurate
does not happen over the span of a few months time frames) that may be required to reach the
or necessarily a year. The CQI process should be agency’s goal.
conducted so that activities are identified and
implemented to obtain continuous movement
toward delivery of a higher level of care.
3
CONTINOUS QUALITY IMPROVEMENT PLAN
Ryan White Title II Recipient Agency:
Purpose of CQI
The purpose of this CQI plan is to assess the quality of care provided by
_______________________________ to its clients in accordance with its mission
statement. The CQI plan serves as a tool to help with improving noted deficits or
weaknesses, and to ensure recommendations made by the Ryan White Peer Review
Committee are incorporated and monitored.
Goals and Objectives
In order to properly assess and improve the quality of care through the CQI process, the
agency needs to consider issues of planning, design, implementation, and monitoring.
Accordingly, the following should be considered:
Develop planning instruments that can integrate data from Peer Review reports,
Client Satisfaction Surveys, outreach activities, community partners and third
party participants, and input from within the agency.
Tailor design of plan to best meet needs - both new and existing - of the delivery
of services provided to clients and augment client satisfaction received from
support system and primary medical care team.
Establish and specify measurements for noticing disparities in administrative and
care functions through the collection of data using valid and credible sampling
methods and noting observations over a period of time.
Utilize appropriate evaluation techniques to determine the effectiveness of
program activities, delivery of care, and administrative activities.
Focus on communication and quality improvement in all aspects of the agency,
and encourage participation not only within the agency but also with the Peer
Review Committee.
Build and maintain relationships with other agencies within the community to
properly assess the needs of the community.
Structure of CQI Plan
1. Framework
The (agency leader’s position) ___________________________ is responsible for the
coordination, planning, design, and implementation of client services. This person is
responsible for approving and monitoring the activities of the CQI team and its quality
improvement activities. The CQI team is under the direction of
________________________.
The Consumer Advisory Board was formed in order to assist in the quality improvement
activities and will participate when and where appropriate. Reports of the quality
improvement activities will be made to the agency leader.
2. Content
The CQI plan is designed to address the following functional units of the agency:
Administration
Primary Medical Care
Case Management
Prevention Case Management
Treatment Adherence
Substance Abuse
Outreach Services/Client Advocacy
Nutritional Counseling
Psychosocial Support Services
Respite/Home Health Services
Housing
**Special attention should be given to areas that have been highlighted as
deficiencies in the Peer Review report.
3. Data Collection
Performance measures will be selected for the major functional units of the agency and
should be reviewed periodically for their appropriateness. Results of these activities
should be shared with the CQI team and incorporated in actions steps where
appropriate. Sources of data can include, but are not limited to:
Client Satisfaction Surveys
Demographic data, data from appointment book
Clinical measures using HIVQUAL software
Appropriate sampling methodology should be used for data collection.
5
4. Assessments and Evaluation
The CQI team will be responsible for evaluating data or designating external sources to
do so.
5. CQI Team and Plan
Once problems have been identified, the CQI team will identify persons within the
agency to develop a corrective action and implement action steps to achieve the
corrective action and the desired outcome. The team should include those who work
closely with the areas of concerns. Where appropriate, collaboration between different
departments in the agency should be promoted as staff members may be closely
working together.
A CQI methodology will be implemented and includes but is not limited to:
Plan, Do, Check, Act (PDCA)
Comprehensive Continuous Integrated Systems of Care (CCISC)
Flow Chart Analysis
Pareto Diagrams/Cause-and-Effect Diagrams
Brainstorming
Observational Studies
Activity Logs
6. Monitoring of CQI
“Feedback” is vital to the success of any CQI plan. Quarterly, or regular monitoring of
the improvement plan may be implemented and scheduled. A calendar of tentative
dates for CQI team meetings and activities should be included as part of the agency’s
formal CQI plan.
7. Communication
Communication and follow-through on activities related to the CQI plan are keys to its
success.
Agency Leader Date
Clinical Supervisor Date
6
IMPROVEMENT PLAN GRID
Major Areas Important Areas of Possible Staff Member Timeline
Patient Concern Solution in charge
Services
7
Major Areas Important Areas of Possible Staff Member Timeline
Patient Concern Solution in charge
Services
8
CQI TEAM STRUCTURE
Mission Statement of Agency:
Purpose
To develop, implement and maintain quality assurance activities within the agency in
accordance with the Agency’s CQI plan regarding administrative and care services.
Goals
Address the goals and objectives listed in the CQI Plan:
a. Develop a plan for addressing program functions
b. Tailor design of plan to specifics of agency
c. Establish and specify measurements to be used
d. Utilize appropriate evaluation techniques
e. Focus on communication and quality improvement
f. Build and maintain internal and external relationships
Address the major functional units of client care:
a. Administration
b. Primary Medical Care
c. Case Management
d. Prevention Case Management
e. Treatment Adherence
f. Substance Abuse
g. Outreach Services/Client Advocacy
h. Nutritional Counseling
i. Psychosocial Support Services
j. Respite/Home Health Services
k. Housing
Categorize goals and projects so priority issues are addressed first
Perform annual evaluation of HIV Quality Management program
Review and update the CQI plan and quality improvement activities quarterly
(suggested)
9
Educate staff on new quality improvement techniques and ideas
Provide assistance and guidance during Peer Review Committee site visits
Develop a CQI calendar/timeline to include mechanism for reporting progress
Team Members
NAME TITLE
Meeting Schedule
CQI Team will meet ____ times a year or as necessary to successfully meet agency
specific actions related to CQI.
Reporting Structure
Copies of team meeting minutes kept
Provide reports of progress or quality activities to relevant persons and groups
10
CQI PROTOCOL
Elements of the CQI Plan should be addressed and reviewed as the action steps require.
Each issue contains a desired, measurable outcome and a corrective action statement.
Action steps should be formulated that address the corrective action statement and the
frequency of the action steps noted. The agency may wish to add more action steps as
required to successfully address the content of the corrective action statement. The CQI
Committee Chair, Executive Director or person responsible for overseeing the
implementation of each action step should sign the appropriate action once it has been
implemented. A Notation box or area is included for elaboration or clarification related
to action steps and/or corrective action. The CQI team should determine the
appropriate action steps, their time frames, and any modifications of corrective actions.
11
SAMPLE CQI TEMPLATE
ISSUE: Board of Directors do not meet as required by bylaws; minutes are not taken, signed, or compiled in a single volume, or
made accessible to interested parties
OUTCOME MEASURE: Board of Directors meets according to bylaws and 100% of all minutes of meetings are complete, signed,
on file in a single volume, and placed in a location easily accessible to interested parties
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1) Dates of meetings held and those scheduled are Annually 1/15/2005 J. Doe
reviewed for frequency consistent with bylaw directives
2) Minutes are reviewed by Executive Director for Upon adoption
appropriate signature of minutes
3) Minutes missing signature are reviewed in Annually
subsequent minutes for evidence of adoption by board
and appropriate signature is retained
4) Minute volume contains all original, signed copies of After adoption
Board meeting minutes of minutes
5) Minute volume is located in a conspicuous location Quarterly
within agency accessible to interested parties
6)
7)
Corrective Action: Minutes are reviewed for proper signature, signature is obtained, minutes are compiled in a single volume and stored in a
conspicuous location within the offices of the agency.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
(This section for extemporaneous notes regarding this issue)
ADMINISTRATION
ISSUE: Board of Directors do not meet as required by bylaws; minutes are not taken, signed, or compiled in a single volume, or
made accessible to interested parties
OUTCOME MEASURE: Board of Directors meets according to bylaws and 100% of all minutes of meetings are complete, signed,
on file in a single volume, and placed in a location easily accessible to interested parties
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Minutes are reviewed for proper signature, signature is obtained, and minutes are compiled in a single volume and stored in
a conspicuous location within the offices of the agency.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
(This section for extemporaneous notes regarding this issue)
13
ADMINISTRATION (CONT)
ISSUE: The Board of Directors have not approved all agency policies and procedures
OUTCOME MEASURE: 100% of adopted policies and procedures contain signatures of appropriate board member(s) or other
agency officers OR signed meeting minutes reflect the adoption of all policies and procedures
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Unsigned policies and procedures are reviewed and re-submitted for appropriate signature/acknowledgement.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
14
ADMINISTRATION (CONT)
ISSUE: A Client Satisfaction Survey is not administered annually
OUTCOME MEASURE: Every year, a Client Satisfaction Survey is administered and a summary of the survey’s quantitative and
qualitative results are on file and available for review
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: A Client Satisfaction Survey will be administered within three months if there has been greater than a 12 month lapse since a
previous satisfaction survey has been administered. Results will be summarized and placed are on file for review.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
15
ADMINISTRATION (CONT)
ISSUE: There is inadequate PLWH/A involvement in the management of the agency
OUTCOME MEASURE: Agency planning and administration reflect multiple strategies for including PLWH/A in planning and
management of agency activities
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Agency programs or activities include PLWH/A as evidenced through existing or the development of activities that ensure
PLWH/A involvement (i.e. meeting rosters with unique ID, minutes of meetings involving agency sponsored where PLWH/A participate and/or
evidence of agency action based on results of client satisfaction survey). Where there exists PLWH/A involvement, documentation consistent with
examples in the Measurement statement will compiled and made accessible to peer review teams.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
16
ADMINISTRATION (CONT)
ISSUE: There are no or incomplete number of signed agreements with providers if agency is a third party provider
OUTCOME MEASURE: 100% of Ryan White reimbursements to clinical service providers are articulated through signed
agreements between the agency and service providers
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: In absence of agreements, one is to be drafted and executed with the service provider stipulating the relationship between
the parties, documentation requirements, and the process for financial reimbursement
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
17
ADMINISTRATION (CONT)
ISSUE: There are no or incomplete documentation of staff credentials and evaluations in agency personnel files
OUTCOME MEASURE: 100% of Personnel files contain evidence of staff credentials
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: 100% of personnel files will be reviewed for evidence of resumes, degrees, reference checks, and annual internal
evaluations.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
18
ADMINISTRATION (CONT)
NOTE: Risk and protective factors are aspects of the agency’s environment or its conduct of business that make it more likely or less likely
(protective factors) that the agency will experience a given problem.
ISSUE: There are no or incomplete documentation of approved risk management plans for the agency and its activities
OUTCOME MEASURE: 100% of all agency activities have Board approved risk management policy plans on file
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Risk management plans will be developed, submitted to Board of Directors for adoption and implemented upon their
approval
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
19
ADMINISTRATION (CONT)
ISSUE: There are no or incomplete policies and procedures for agency activities; policies and procedures have not been
approved by Board of Directors
OUTCOME MEASURE: The agency shall have a manual with current policies and procedures approved by the Board of Directors
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: A policies and procedures manual will be developed within six months and adopted by the Board of Directors
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
20
ADMINISTRATION (CONT)
ISSUE: There is no Ryan White II Manual (latest version) or the manual is not easily accessible for reference
OUTCOME MEASURE: The agency shall have a current copy of the Ryan White Program Manual and is easily accessible for
reference
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: A copy of the Ryan White Program Manual will be obtained and is easily accessible
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
21
ADMINISTRATION (CONT)
ISSUE: All clients are not screened for Medicaid eligibility
OUTCOME MEASURE: 100% of clients eligible for Ryan White services will have their Medicaid eligibility determined and the
determination will be filed in the client record
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Medicaid eligibility determination will be initiated at client intake and completed within six months of Ryan White services
initiation. Existing client charts will be reviewed for appropriate documentation.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
22
ADMINISTRATION (CONT)
ISSUE: There is no HIV-specific CQI plan approved by the clinical supervisor and/or agency leader
OUTCOME MEASURE: There is a HIV-specific CQI plan approved by the clinical supervisor and/or agency leader.
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Agency works toward compilation and adoption of a CQI plan based on improving client health and expanding efficiency
and effectiveness of the agency.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
23
ADMINISTRATION (CONT)
ISSUE: Agency invoices do not reflect the signature of appropriate and authorized agency official.
OUTCOME MEASURE: 100% of invoices are signed off by authorized agency official.
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: A procedure for obtaining authorized agency signature on all invoices will be adopted and implemented.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
24
ADMINISTRATION (CONT)
ISSUE: There is no or inadequate documentation of agreements with key access points
OUTCOME MEASURE: 100% of all informal and formal access points to key referral services are supported and evidenced by
written agreements.
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action:
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
25
ADMINISTRATION (CONT)
ISSUE: There is no or inadequate quality assurance plan.
OUTCOME MEASURE: Agency shall develop and implement a quality assurance plan.
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Development and implementation of a quality assurance plan.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
26
ADMINISTRATION (CONT)
ISSUE: Travel files of employees are incomplete
OUTCOME MEASURE: 100% of travel files will have complete documentation showing destination and arrival of employee
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL travel files will be reviewed for documentation of destination and arrival of employee.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
27
ADMINISTRATION (CONT)
ISSUE: Client satisfaction survey is not offered or has insufficient return rate
OUTCOME MEASURE: 15% of clients will return administered Client Satisfaction Survey that is offered and results are compiled
and available
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client Satisfaction Survey administered according to agency policy and evidence of quantified results are on file.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
28
ADMINISTRATION (CONT)
ISSUE: Client charts do not contain evidence of financial reimbursement for services provided client where agency serves as a
third party provider
OUTCOME MEASURE: 100% of client charts contain evidence of financial accountability provided by agency, if agency is a third
party provider
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for the appropriate documents in order for agency to assume third party provider
responsibilities.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
29
PRIMARY MEDICAL CARE
ISSUE: Missing client release of information forms or expired release forms from client records
OUTCOME MEASURE: 100% of client records contain signed release of client information form and (contain expiration dates of
no longer than one year from date of signature) are updated annually
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client files are reviewed for information release form/updated forms before any exchange of information with third parties
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
30
PRIMARY MEDICAL CARE (CONT)
ISSUE: Client chart(s) do not contain, or contain approved laboratory verification of HIV+ status
OUTCOME MEASURE: 100% of client charts contain approved laboratory verification of HIV+ status
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts are reviewed for evidence of CDC approved laboratory tests and clients with missing evidence of status tested
and results placed in client record
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
31
PRIMARY MEDICAL CARE (CONT)
ISSUE: Client medical records do not reflect CDC/HRSA compliance with current medical standards of care for HIV infected
persons
OUTCOME MEASURE: 100% of medical records reflect CDC/HRSA compliance with current medical standards of care for HIV
infected persons
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts are reviewed by qualified personnel to assess compliance with CDC/HRSA medical standards of care for HIV
infected persons
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
32
PRIMARY MEDICAL CARE (CONT)
ISSUE: Client charts do not contain or are incomplete for health maintenance documentation, HIV and other disease risk-
reduction measures
OUTCOME MEASURE: 100% of charts contain health maintenance documentation, HIV and other disease risk-reduction
measures
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1) i.e. 10% of client charts will be reviewed for the
following documentation, but not limited to these
examples: immunizations, eye and dental exams, Pap
smears, nutritional counseling and PSA/rectal exams.
2)
3)
4)
5)
6)
7)
Corrective Action: A process for client chart review will be designed and implemented to review for health maintenance documentation and
other disease risk-reduction measures
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
33
PRIMARY MEDICAL CARE (CONT) - (DIRECT SERVICE PROVIDERS ONLY)
ISSUE: Service providers do not adhere to current standards for preventing opportunistic infections in HIV infected persons
OUTCOME MEASURE: 100% adherence of service provider to current standards for preventing opportunistic infections in HIV
infected persons
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1) Ex: Documentation of drug prescriptions, and
medical advice in medical records
2)
3)
4)
5)
6)
7)
Corrective Action: Recommendation that medical service providers include documentation of treatment adherence in medical records
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
34
PRIMARY MEDICAL CARE (CONT) - (DIRECT SERVICE PROVIDERS ONLY)
ISSUE: Clients are not on ART although clinically indicated
OUTCOME MEASURE: 100% of clients are offered ART where clinically indicated
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL medical records are reviewed for verification of need for ART, and documentation indicating ART prescriptions given
and/or client rejection of drugs.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
35
PRIMARY MEDICAL CARE (CONT) - (DIRECT SERVICE PROVIDERS ONLY)
ISSUE: Medication and treatment records are not current and complete
OUTCOME MEASURE: 100% of client records will reflect up-to-date medication and treatment information and activity
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL medical records will be reviewed for completeness and updated status.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
36
PRIMARY MEDICAL CARE (CONT) - (DIRECT SERVICE PROVIDERS ONLY)
ISSUE: Laboratory reports are either not reviewed, dated, or initialed by appropriate clinical staff
OUTCOME MEASURE: 100% of laboratory reports are reviewed, dated, and initialed by appropriate clinical staff
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action ALL client charts will be reviewed for completeness of laboratory reports and approval with clinical supervisor’s signature.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
37
PRIMARY MEDICAL CARE (CONT) - (DIRECT SERVICE PROVIDERS ONLY)
ISSUE: Client charts do not reflect client participation in medical care plan
OUTCOME MEASURE: 100% of client charts reflect client’s participation in client’s medical care plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action ALL client charts reflect involvement of client in medical care plan
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
38
CASE MANAGEMENT
ISSUE: Case Management standards are not in place and/or are not consistent with VDH Revised 3/04 HIV/AIDS Case
Management Standards
OUTCOME MEASURE: 100% of client files reflect consistency with VDH Case Management Standards
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Review of case management policies and procedures to incorporate CM standards.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
39
CASE MANAGEMENT (CONT)
ISSUE: Client charts do not contain completed intake tool; evidence of client participation is not evident (client signature
missing) including a client-centered assessment of their HIV status and its implications
OUTCOME MEASURE: 100% of client charts contain a completed intake tool with evidence of client participation including a
thorough client-centered assessment of their HIV status and implications
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts will be reviewed for evidence of appropriate documentation enabling access and availability of key referral
services
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
40
CASE MANAGEMENT (CONT)
ISSUE: Client charts do not contain evidence of Ryan White II eligibility criteria
OUTCOME MEASURE: 100% of client charts contain evidence of eligibility criteria qualifying the client for Ryan White II services
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client chart reviews looking for evidence of eligibility for Ryan White II services.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
41
CASE MANAGEMENT (CONT)
ISSUE: Client charts do not contain appropriate documentation of informed confidentiality statutes, grievance policies or have
missing client signatures indicating acknowledgment of statutes and policies
OUTCOME MEASURE: 100% of client charts contain documentation of informed confidentiality statutes, grievance policies and
client signature indicating acknowledgment
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of signed Releases or No Releases, and confidentiality statement signed
and dated by client and case manager
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
42
CASE MANAGEMENT (CONT)
ISSUE: Client charts do not contain evidence of patient involvement in agency developed care plan
OUTCOME MEASURE: 100% of client charts contain evidence of patient involvement agency developed care plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client chart reviews looking for appropriate evidence of client involvement in care plans.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
43
CASE MANAGEMENT (CONT)
ISSUE: Case management services are not routinely available to all Ryan White clients.
OUTCOME MEASURE: 100% of all case management services are routinely available to all Ryan White clients.
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts are reviewed for case management services consistent with acuity level established at intake or adjusted for
re-evaluation.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
44
CASE MANAGEMENT (CONT)
ISSUE: Active client charts do not reflect parameters and criterion consistent with “active” designation as defined by VDH Case
Management Standards.
OUTCOME MEASURE: 100% of client charts reflect parameters and criterion that define an active client consistent with the VDH
Revised 3/04 HIV/AIDS Case Management Standards.
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1) Ex: All CM staff receive training in VDH CM
Standards
2)
3)
4)
5)
6)
7)
Corrective Action: “Active” Client charts are reviewed for criterion consistent with VDH Case Management standards.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
45
CASE MANAGEMENT (CONT)
ISSUE: Client records do not indicate a reassessment of needs and appropriate updating of client service plan
OUTCOME MEASURE: 100% of client records contain evidence of a reassessment of client needs and this is reflected in
revisions to the client’s service plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts are reviewed for reassessment of client needs on a timely basis and service plans reflect reassessment
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
46
CASE MANAGEMENT (CONT)
ISSUE: Client service plan does not reflect reassessment of needs, including client acknowledgment of service plan
OUTCOME MEASURE: 100% of client records reflect client participation in Service Plan development and reassessment of the
plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Service Plan must be signed both by the Case Manager and client, client needs must be reassessed and level of reassessed
needs must be evident in client chart
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
47
PREVENTION CASE MANAGEMENT
ISSUE: PCM client service plans do not contain individual written prevention plans or do not indicate client participation that
include specific HIV risk reduction strategies
OUTCOME MEASURE: 100% of client charts contain individual written Prevention Plans with client participation, which include
specific HIV risk reduction strategies
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL PCM client charts will be reviewed for evidence of written Prevention Plan and client signature
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
48
PREVENTION CASE MANAGEMENT (CONT)
ISSUE: PCM client charts do not contain evidence of regular meetings with Case Manager to monitor Prevention Plan including
behavioral risk reduction objectives
OUTCOME MEASURE: 100% of client charts contain evidence of regular meetings with Case Manager to monitor HIV
behavioral risk-reduction objectives made in Prevention Plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL PCM client charts will be reviewed for evidence of confidential progress notes and documentation of how HIV
behavioral risk-reduction objectives are being met and what can be done to facilitate client involvement.
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
49
PREVENTION CASE MANAGEMENT (CONT)
ISSUE: PCM client charts do not reflect adherence to ART and other drug therapies
OUTCOME MEASURE: 100% of client charts address adherence issues for those receiving ART and other drug therapies
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of any adherence issues and suggestions/resolutions for improvement
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
50
PREVENTION CASE MANAGEMENT (CONT)
ISSUE: PCM clients that have substance abuse problems are not necessarily referred for appropriate drug and/or alcohol
treatment
OUTCOME MEASURE: 100% of PCM clients that have substance abuse problems are referred to appropriate drug and/or
alcohol treatment
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL substance abuse client charts will be reviewed for appropriate referral services documentation, and follow up visits
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
51
TREATMENT ADHERENCE SERVICES
ISSUE: Substance abuse clients are not treated or counseled by appropriately educated and experienced staff
OUTCOME MEASURE: 100% of clients are attended to by appropriately educated and experienced staff members
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of appropriately trained medical nurses, social workers or other
professionals providing services
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
52
TREATMENT ADHERENCE SERVICES (CONT)
ISSUE: Substance abuse clients are not treated or counseled by appropriately educated and experienced staff
OUTCOME MEASURE: 100% of clients are attended to by appropriately educated and experienced staff members
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of appropriately trained medical nurses, social workers or other
professionals providing services
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
53
TREATMENT ADHERENCE SERVICES (CONT)
ISSUE: Client chart reflects inadequate documentation to determine adherence to intervention plan
OUTCOME MEASURE: 100% of client charts with intervention plan reflect adherence to plan and that the plan is regularly
monitored
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of adherence to intervention plan and regular monitoring of intervention
plan
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
54
SUBSTANCE ABUSE SERVICES
ISSUE: Client eligibility for substance abuse services provided by agency or third-party agency is not determined
OUTCOME MEASURE: 100% of client eligibility is determined by agency for provision of services
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts receiving substance abuse services will be reviewed for documentation of eligibility status
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
55
SUBSTANCE ABUSE SERVICES (CONT)
ISSUE: Clients deemed ineligible for services have not been referred for services or referral/follow up is not noted in the
client’s chart
OUTCOME MEASURE: 100% of clients deemed ineligible have referrals for appropriate services noted and documented in
charts
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts receiving substance abuse services will be reviewed for documentation of eligibility status
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
56
SUBSTANCE ABUSE SERVICES (CONT)
ISSUE: Clients receiving substance abuse services do not contain MOAs with third party providers for receipt of client
information back to referring agency
OUTCOME MEASURE: 100% of client charts receiving substance abuse services contain MOAs listing all pertinent information
that affects clients
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for MOAs with client signature accepting terms and conditions listed within
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
57
SUBSTANCE ABUSE SERVICES (CONT)
ISSUE: Substance abuse services provided to clients are not provided by adequately educated and experienced staff members
OUTCOME MEASURE: Adequately educated and experienced staff members attend to 100% of substance abuse
clients
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of services provided by adequately trained health and/or
human service professionals
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
58
SUBSTANCE ABUSE SERVICES (CONT)
ISSUE: Charts of clients receiving substance abuse services do not indicate that there has been a reassessment of client needs
OUTCOME MEASURE: 100% of client charts contain evidence that there has been a reassessment of client needs
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of reassessment tests and results are made available
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
59
SUBSTANCE ABUSE SERVICES (CONT)
ISSUE: Charts of clients receiving substance abuse services do not indicate a SA treatment plan and/or that there has been a
reassessment of client needs
OUTCOME MEASURE: 100% of client charts contain evidence of a SA treatment plan and that there has been a
reassessment of client needs
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of treatment plan, with client signature and regular
monitoring of treatment plan
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
60
OUTREACH SERVICES/CLIENT ADVOCACY
ISSUE: Client charts do not contain evidence of appropriate nutritional education for clients, including absence of a nutritional
assessment and/or the client care plan does not address nutritional objectives
OUTCOME MEASURE: 100% of client charts contain evidence of 1) client nutritional education regarding their HIV status, 2) a
nutritional assessment, and 3) appropriate nutrition is reflected in care plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts will be reviewed for evidence of clients’ nutritional assessment, education lesson plan or forms giving
nutritionally sound advice to clients, and client signature acknowledging information
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
61
OUTREACH SERVICES/CLIENT ADVOCACY (CONT)
ISSUE: Client charts do not contain evidence of outreach encounter forms, and referral/follow-up documentation
OUTCOME MEASURE: 100% of client charts contain evidence of outreach encounter forms, and referral/follow-up
documentation
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for evidence of use of outreach encounter forms, and referral/follow-up
documentation
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
62
OUTREACH SERVICES/CLIENT ADVOCACY (CONT)
ISSUE: Client charts do not contain evidence of a structured referral process for clients who need help and follow up efforts are
not evident
OUTCOME MEASURE: 100% of client charts contain evidence of a structured referral process for clients who need help and
follow up efforts are evident
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: ALL client charts will be reviewed for documentation of referral services and follow up visits
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
63
64
Outreach Activities are effective, appropriate and Y N Y N Y N Y N
evidence of quality management plans to ensure good Qtr1 Qtr1 Qtr2 Qtr2 Qtr3 Qtr3 Qtr4 Qtr4
quality of care.
Measurement: Documentation of frequent monitoring of
outreach activities for improvement and effectiveness, and ___ ___ ___ ___ ___ ___ ___ ___
evidence of customer feedback form and quantified results.
Corrective Action: Evaluation surveys should be handed
___ ___ ___ ___ ___ ___ ___ ___
out to gauge effectives off outreach programs and quality
management plan should be out into effect for improvement.
NOTATIONS:
. Y N Y N Y N Y N
Qtr1 Qtr1 Qtr2 Qtr2 Qtr3 Qtr3 Qtr4 Qtr4
Measurement: 10% of client charts will be reviewed for
documentation of referral services, and follow up visits.
___ ___ ___ ___ ___ ___ ___ ___
Corrective Action:.
___ ___ ___ ___ ___ ___ ___ ___
65
NOTATIONS:
66
NUTRITIONAL COUNSELING
ISSUE: Client charts do not contain evidence of appropriate nutritional education for clients, including absence of a nutritional
assessment and/or the client care plan does not address nutritional objectives
OUTCOME MEASURE: 100% of client charts contain evidence of 1) client nutritional education regarding their HIV status, 2) a
nutritional assessment, and 3) appropriate nutrition is reflected in care plan
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts will be reviewed for evidence of clients’ nutritional assessment, education lesson plan or forms giving
nutritionally sound advice to clients, and client signature acknowledging information
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
67
NUTRITIONAL COUNSELING (CONT)
ISSUE: Nutritional counseling is not provided by appropriate personnel
OUTCOME MEASURE: 100% of client charts contain evidence of counseling performed by qualified personnel according to the
policy of the agency and conducted outside of any primary care visit
Action Steps (Steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts will be reviewed for evidence of a visit to qualified personnel providing nutritional counseling to clients
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
68
NUTRITIONAL COUNSELING (CONT)
ISSUE: For clients provided food supplements, their chart does not contain a recommendation or prescriptions for food
supplements
OUTCOME MEASURE: 100% of clients provided food supplements, their charts contain prescriptions for food supplement or a
recommendation from primary care provider
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Client charts will be reviewed for evidence of a visit to qualified personnel providing nutritional counseling to clients
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
69
PSYCHOSOCIAL SUPPORT SERVICES
ISSUE: Client psychosocial support services are led by persons who do not have adequate training or credentials
OUTCOME MEASURE: 100% of providers of support services are qualified to lead psychosocial activities as identified by the
agency
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Qualified personnel are retained to provide client psychosocial services
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
70
PSYCHOSOCIAL SUPPORT SERVICES (CONT)
ISSUE: Client psychosocial support services are led by persons who do not have adequate training or credentials
OUTCOME MEASURE: 100% of support services staff or volunteer(s) has completed approved statewide HIV/AIDS training no
later than 6 months after employment date
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1) Example: Evidence of completion of statewide
training as well as some sort of crisis intervention
training evident in personnel files.
2)
3)
4)
5)
6)
7)
Corrective Action: Training is scheduled immediately and completed
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
71
PSYCHOSOCIAL SUPPORT SERVICES (CONT)
ISSUE: Psychosocial support services are inadequately or not documented
OUTCOME MEASURE: 100% of psychosocial support services are evidenced by signed and dated attendance rosters, a brief description of
support programs listing goals and objectives, and list of discussion topics are maintained on file
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Training is scheduled for support services staff on appropriate documentation and record keeping
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
72
ISSUE: Psychosocial support services are inadequately or not documented
OUTCOME MEASURE: 100% of psychosocial support services are evidenced by signed and dated attendance rosters, a brief description of
support programs listing goals and objectives, and list of discussion topics are maintained on file
Action Steps (steps that reflect corrective action. To be completed by agency)
Date(s) Person
Action Step Frequency Completed Responsible Signature
1)
2)
3)
4)
5)
6)
7)
Corrective Action: Training is scheduled for support services staff on appropriate documentation and record keeping
AGENCY NOTES REGARDING ISSUE AND ACTION STEPS:
73
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